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Vascular Surgery (aneurysm (abdominal aortic aneurysm (causes:…

- - - - arterial wall forms the wall of the aneurysm
    - - surrounding tissues form the wall of the aneurysm
  - - - atherosclerosis
      - infection
        syphilis, E. coli, salmonella
      - trauma
      - genetic
        Marfan's, Ehlers-Danlos
    - - normal <3cm
      - medium 4.5-5.4cm
      - large <5.5cm
      - small 3-4.4cm
    - - most asymptomatic
      - severe epigastric pain, radiating to back
        rapid expansion/rupture
      - rupture
        
        hypotension
        
        tachycardia
        
        profound anaemia
        
        sudden death
      - haematemesis - aortoduodenal fistula
        rare
    - - best outcomes from surgery if:
        
        diameter >5.5cm
        
        expanding >1cm/year
        
        symptomatic
      - medical
        
        control of hypertension
        
        smoking cessation
        
        lipid-lowering drugs
      - surgical
        
        open
        
        endovascular stenting (EVAR)
        
        laparoscopic
  - - - ascending
        
        Marfans
        
        hypertension
      - descending/arch
        
        syphilis
        
        atherosclerosis
    - - stridor
      - haemoptysis
      - hoarseness
      - haematemesis
- - - - rest pain
        
        constant pain
        
        opiate analgesia
        
        often in foot
        
        relieved by cold and lowering foot
      - reduced blood pressure in ankle
      - 90% require reconstruction/angioplasty
      - 25% amputation rate
    - - relieved at rest
      - pain in muscle on exertion
      - commonest in calf
        also in buttock/hip/thigh
      - claudication distance (reproducible)
    - - 1 - asymptomatic
      - 2 - intermittent claudication
      - 3 - rest pain/nocturnal pain
      - 4 - necrosis/gangrene
    - - smoking
      - diabetes
      - hypercholesterolaemia
      - hypertension
      - thrombophilia premature atherosclerosis
      - homocysteinaemia
    - - spinal canal claudication
      - osteoarthritis
      - peripheral neuropathy
      - popliteal artery entrapment
      - venous claudication
      - fibromuscular dysplasia
      - Buerger's disease
    - - medical
        
        risk factor management
        
        low dose aspirin
        reduces risk of MI/CVA
      - pharmacological
        
        cilostazol
        (PDE III inhibitor)
        
        naftidrofuryl
        (vasodilator - 5HT2 inhibitor)
      - surgical
        
        percutaneous transluminal angioplasty
        
        bypass procedures
        
        amputation
  - - - pain
      - pallor
      - parasthesia
      - paralysis
      - perishingly cold
    - - embolic disease
        
        cardiac thrombus
        
        cardiac arrhythmias
        
        rheumatic fever
        
        aneurysm thrombus
        
        thrombus on atherosclerotic plaques
        
        atrial myxoma
      - thrombotic disease
        
        acute thrombus on atherosclerotic stenosis
        
        thrombophilia
        
        malignancy
        
        external compression
        e.g. cervical rib
        
        prosthetic/venous grafts
        
        popliteal aneurysms
    - - medical
        
        heparin
        
        long term warfarin if post-MI or AF
      - surgical
        
        graft thrombolysis
        
        angioplasty
        
        embolectomy
        
        bypass graft
        
        fasciotomy
- - - - blood penetrates diseased medial area
        
        intimal laminar plane is cleaved
    - - timing
      - anatomical
        
        A - involves aortic arch and valve proximal to left subclavian artery origin
        
        B - involves descending thoracic aorta distal to left subclavian artery origin
- - - - pain
      - cramps
      - restless leg
    - - oedema
      - eczema
      - ulcers
      - haemosiderin
      - phlebitis
      - atrophie blanche
      - lipodermatosclerosis
    - - dilatation of saphenous vein at SFJ
      - cough impulse
      - bluish tinge
  - - - commonly involves saphenous veins
      - associated with varcosities
      - painful, tender, cord-like structure
      - associated redness and swelling
      - inflammation of the vein wall leading to thrombus formation
    - - thrombus forms in the vein
      - any inflammation is secondary to thrombus formation
      - symptoms
        
        pain in calf
        
        swelling
        
        redness
        
        engorged superficial veins
      - Homan's sign
        
        pain in calf on dorsiflexion
      - complete occlusion can lead to cyanotic discolouration
      - PE more common with iliofemoral thrombosis